Improving the Quality of Health Care
for Mental and Substance-Use
Conditions
A Report in the Quality Chasm Series
Study Sponsors
• Annie E. Casey Foundation
• CIGNA Foundation
• National Institute on Alcohol Abuse and
Alcoholism
• National Institute on Drug Abuse
• Substance Abuse and Mental Health Services
Administration
• Robert Wood Johnson Foundation
• Veterans Health Administration
COMMITTEE ON CROSSING THE QUALITYCHASM:
ADAPTION TO MENTAL HEALTH AND ADDICTIVE DISORDERS
MARY JANE ENGLAND (Chair) - Regis College, Weston, MA.
PAUL S. APPELBAUM - University of Massachusetts Medical School
SETH BONDER - Consultant in Systems Engineering, Ann Arbor
ALLEN DANIELS - Alliance Behavioral Care, Cincinnati
BENJAMIN DRUSS - Emory University, Atlanta
SAUL FELDMAN - United Behavioral Health, San Francisco
RICHARD G. FRANK - Harvard Medical School
THOMAS L. GARTHWAITE - Los Angeles County Dept of Health Services
GARY GOTTLIEB - Brigham and Women’s Hospital & Harvard Medical School
KIMBERLY HOAGWOOD - Columbia University & NY Office of Mental Health
JANE KNITZER - National Center for Children in Poverty, New York.
COMMITTEE ON CROSSING THE QUALITYCHASM:
ADAPTION TO MENTAL HEALTH AND ADDICTIVE DISORDERS
A. THOMAS MCLELLAN - Treatment Research Institute, Philadelphia.
JEANNE MIRANDA - UCLA.
LISA MOJER-TORRES - Attorney in civil rights and health law, Lawrenceville, NJ.
HAROLD ALAN PINCUS - University of Pittsburgh School of Medicine, and RAND - University of
Pittsburgh Health Institute
ESTELLE B. RICHMAN - Pennsylvania Department of Public Welfare
JEFFREY H. SAMET - Boston University Schools of Medicine and Public Health and Boston Medical
Center
TOM TRABIN - Consultant in behavioral healthcare and informatics, El Cerrito, CA.
MARK D. TRAIL - Georgia Department of Community Health.
ANN CATHERINE VEIERSTAHLER - Nurse, advocate, person with bipolar illness. Milwaukee, WI
CYNTHIA WAINSCOTT Chair, National Mental Health Association, Cartersville, Georgia.
CONSTANCE WEISNER - University of California, SF, and Northern California Kaiser Permanente.
Crossing the Quality Chasm
a new HEALTH system for the 21st century (IOM, 2001)
M/SU Health Care
Compared to General Health Care
• Increased stigma,
discrimination, & coercion
• More separate care
delivery arrangements
• Patient decision-making
ability not as anticipated
/supported
• Less involvement in the
NHII and use of IT
• Diagnosis more subjective
• More diverse workforce
and more solo practice
• A less developed quality
measurement &
improvement
infrastructure
• Differently structured
marketplace
Overarching Recommendation
The aims, rules, and strategies for redesign set
forth in Crossing the Quality Chasm should
be applied throughout M/SU health care on
a day-to-day operational basis but tailored
to reflect the characteristics that distinguish
care for these problems and illnesses from
general health care.
Mental, substance-use,
and general health
• Mental and substance-use conditions are
frequently intertwined;
• Both highly influence general health;
• Improving care delivery and health
outcomes for any one of the three depends
upon improving care delivery and outcomes
for the others.
Mental and substance-use problems
are pervasive, often unrecognized, and
if not resolved, ultimately make
themselves known – if not initially as
mental or substance use problems,
then as general health conditions.
Overarching Recommendation
Health care for general, mental, and
substance-use problems and illnesses
must be delivered with an understanding
of the inherent interactions between the
mind/brain and the rest of the body.
Improving M/SU health care
requires actions by:
• Clinicians
• Health care
organizations
• Health plans
• Purchasers
• State policy officials
• Federal policy
officials
• Accrediting bodies
• Institutions of higher
education
• Funders of research
Individual clinicians should:
• Support consumer decision-making and treatment
preferences;
• Use illness self-management practices;
• Have effective linkages with community resources;
• When coercion unavoidable, make the process transparent;
• Screen for co-morbid conditions;
• Routinely assess treatment outcomes;
• Routinely share clinical information with other providers;
• Practice evidence-based care coordination; and
• Be involved in designing the National Health Information
Infrastructure (NHII).
Organizations providing care should:
• Have polices to enable and support all actions
required of clinicians (on prior slide);
• Involve patients / families in design,
administration, and delivery of services;
• If serving a high-risk population (e.g., child
welfare, criminal and juvenile justice) screen all
entrants for M/SU problems
• Involve leadership and staff in developing the
National Health Information Infrastructure (NHII).
Health plans and purchasers should
• For consumers with chronic M/SU illnesses, pay for peer
support and illness self-management programs that meet
standards;
• Use and provide consumers with comparative info on the
quality of M/SU services to select providers;
• Remove payment, service exclusion, benefit limits and
other coverage barriers to accessing effective screening,
treatment and coordination;
• Support development of a quality measurement and
reporting infrastructure;
Health plans and purchasers (cont.)
• Require all contracting organizations to appropriately share
patient information;
• Provide incentives for the use of electronic health records
and other IT;
• Use tools to reduce adverse risk selection of M/SU
treatment consumers; and
• Use measures of quality and coordination of care in
purchasing / and oversight.
• Associations of purchasers work to reduce variation in
reporting / billing requirements.
State policy-makers should:
• Make coercion policies transparent, use info on comparative quality of
providers and evidence-based treatment, and afford consumers choice;
• Revise laws and other policies that obstruct communication between
providers;
• Create high level mechanisms to improve collaboration and
coordination across agencies;
• Use purchasing practices that incentivize use of EHRs and other IT;
• Enact parity for coverage of M/SU treatment;
• Reorient state procurement processes toward quality; and
• Reorient state purchasing to give more weight to quality and reduce
emphasis on grant-based mechanism
DHHS to charge or create entities to:
• Identify evidence–based practices;
• Develop procedure codes for administrative data
sets;
• Use evidence–based approaches to dissemination
and promote uptake of evidence-based practices;
• Assure use of general health care opinion leaders
(e.g., CDC, AHRQ) in dissemination;
• Fulfill essential quality measurement and
reporting functions;
• Provide leadership in quality improvement
activities; and
• Improve coordination among federal agencies.
Federal Government also should
• Revise laws, rules, other polices that obstruct sharing of
information across providers;
• Fund demonstrations to transition to evidence-based care
coordination;
• Ensure that the emerging NHII addresses M/SU health
care;
• Authorize and fund an ongoing Council on the Mental and
Substance-Use Health Care Workforce similar to the
Council on Graduate Medical Education (Congress);
• Support M/SU faculty leaders in health profession schools;
• Provide leadership, development support and funding for
R&D on QI in M/SU health care.
Accreditors of M/SU health care
organizations should:
Adopt standards requiring:
• Patient-centered decision-making throughout care;
• Involvement of consumers in design,
administration, and delivery of services;
• Effective formal linkages with community
resources; and
• Use of evidence-based approaches to coordinating
mental, substance-use and general health care.
Institutions of higher education
should:
• Increase interdisciplinary teaching and
learning to facilitate core competencies
across disciplines; and
• Facilitate the work of the Council on the
Mental and Substance-Use Health Care
Workforce.
Funders of research should support:
• Development and refinement of screening, diagnostic, and
monitoring instruments to assess response to treatment;
• A set of M/SU “vital signs”: a brief set of indicators—for
patient screening, early identification of problems and
illnesses, and for repeated use to monitor symptoms and
functional status.
• Research approaches that address treatment effectiveness
and quality improvement in usual settings of care.
• Research designs in addition to randomized controlled
trials, that involve partnerships between researchers and
stakeholders, and create a “critical mass” of
interdisciplinary research partnerships involving usual
settings of care.